Social Security Disability - Medicare Insurance Supplement/Advantage Plans

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Lynnwood
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Date Joined May 2005
Total Posts : 7018
   Posted 12/15/2009 9:57 PM (GMT -7)   
With all of the expensive medications we Lupies sometimes end up on, and since it's the time of year when folks using Medicare Supplemental or Advantage Plans can switch plans -- I thought maybe a discussion of what folks have found out might be in order.

This is my first chance to get a plan -- in the past with employers insurance I've always paid the extra cost for PPO's, as I hate someone else telling me which doctors I can or can't see.

Now they are all looking the same, with premiums ranging from $0 month to $300+ monthly - but you can't hardly tell if all of your drs are on the list, or how much it might be to see them when they *are not* on the list....I don't even see a plan that covers the very good hospital 1.5 miles from home. And then of course the drug coverage is equally mistifing....

What criteria do you guys use to make the final descion? Of course, this only applies to those who don't have employer, retirement, or government policies of some sort covering them...

Anyone with any enlightenment out there?
Lynnwood, Lupus & Sjogren's Moderator
"Life is far too important to be taken seriously" - Oscar Wilde

Post Edited (Lynnwood) : 12/16/2009 10:17:20 AM (GMT-7)


PattyLatty
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Date Joined Mar 2006
Total Posts : 2570
   Posted 12/16/2009 6:47 AM (GMT -7)   
Good topic, Lynnwood, and one that may apply to some of us sooner than we expected if the rumor is correct that rather than going with a public option, the govt may simply lower the age for medicare to 55.
SLE, fibro, renauds, restless leg, hiatal hernia, double vision, migraines, costocondritis.

prednisone, plaquenil, leflunomide, neurontin, synthroid, triamterene, actonel, niaspan, lyrica, tri-est, cymbalta, acifex


Lynnwood
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Date Joined May 2005
Total Posts : 7018
   Posted 12/16/2009 10:15 AM (GMT -7)   
This applies to anyone getting Social Security Disability, so age isn't the biggest factor by far.
Lynnwood, Lupus & Sjogren's Moderator
"Life is far too important to be taken seriously" - Oscar Wilde


cured4real?
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Date Joined Dec 2005
Total Posts : 1944
   Posted 12/16/2009 10:26 PM (GMT -7)   
Lynnwood,
Both my mom and I were on Humana PPO, and she was also on the HMO, and pretty much the whole state of Florida no longer takes Humana MAPs. Mayo clinic will not accept anyone who is on a medicare advantage plan butwill take you with straight medicare. I was upset about giving up my map at first because I had the PPO and it cost me nothing, but I was really glad I did. My copays were much higher on the MAP plan, and they were also getting my medicare money rerouted to them and so the state wasn't paying it for me. So that was another problem that cost me. Then it went up to like 200 a month. And they are managed care to some extent. I have consistently paid much more in copays with a MAP. And the clinics don't like them because they are just getting in the way of people and their benefit and causing problems. I thought that it would save me on hospitalization and surgery, but it didn't, I still have to pay my deductible each year. Mayo really doesnt like them at all and I understand why now. I'm much better off now, and my mom has a much wider range of docs on straight medicare, and the docs always write off alot for medicare patients. My dad has the one through AARP and is paying a fortune for it and I think its a waste of money, but its his money so, there you go.

As an example, I was paying 30 to see a specialist and 15 to see my family doctor on humana ppo. Now I only pay 17 to see any doctor, and I have alot o specialists. Also, the facilities and other places were charging me higher than their usual medicare rates on some tests and stuff, andI was having alot higher bills. I qualify for indigent discounts at my hospital and that helps alot with deductibles and such. So there are other ways to make it through the deductible.

Iknow this isn't the most positive review. but it really was hard for me to understand how these insurance companies were going to make any money off medicare patients if they areonly getting the medicare approved amount. The deal is they are not payingout tothe docs and hospitals in any type of timely fashion, and are dictating care. And they are subsidized by the government, which is money betterspent paying off all the IOUs taken out of the medicare trust fund.
Love, Marji
Ills--Sjogrens-Lupus cond., AI polygland. dysfunction 2, hyper/hypopigment, scoliosis,kyphosis,stenosis, deg.,O.A.,spine surgeries, salivary/lymphectomies, NASH, COPD, RLS, UT/GI bleeds, hystero, brain/nerve damage,TB
Meds--INH,Plaquenil, Evoxac, Metformin, Synthroid, HCTZ, HRT and Lidocaine patchs, Voltaren gel, Klonopin, Vicodin, Restasis, Albuterol, steroids


cured4real?
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Date Joined Dec 2005
Total Posts : 1944
   Posted 12/16/2009 10:28 PM (GMT -7)   
Oh--the best review might be to ask someone who works in billing at a doctors office or hospital. I'm sure they will have a knowledgeable opinion.
Love, Marji
Ills--Sjogrens-Lupus cond., AI polygland. dysfunction 2, hyper/hypopigment, scoliosis,kyphosis,stenosis, deg.,O.A.,spine surgeries, salivary/lymphectomies, NASH, COPD, RLS, UT/GI bleeds, hystero, brain/nerve damage,TB
Meds--INH,Plaquenil, Evoxac, Metformin, Synthroid, HCTZ, HRT and Lidocaine patchs, Voltaren gel, Klonopin, Vicodin, Restasis, Albuterol, steroids


Lynnwood
Forum Moderator


Date Joined May 2005
Total Posts : 7018
   Posted 12/16/2009 11:01 PM (GMT -7)   
Yeah, my rheumy's billing office said avoid secure horizon / united heathcare -- which pretty much means avoid AARP.

I'm not seeing anything about a Humana 'MAP' plan -- I was basically looking at PPO's.

Right now my dr visits are low, but my med costs are high...
Lynnwood, Lupus & Sjogren's Moderator
"Life is far too important to be taken seriously" - Oscar Wilde


Lynnwood
Forum Moderator


Date Joined May 2005
Total Posts : 7018
   Posted 12/17/2009 12:37 AM (GMT -7)   
After studying these, particularly Aetna & Humana plans, I've come to the following conclusion -- if you want to pick your own doctors (which I want the freedom to do) you'll want a PPO plan, where you will, worst case, always be charged out of network rates of 30% or 35% vs Medicare's 20%.

Some, but not all, plans have maximum-out-of-pocket limits -- this is the benefit of these plans. With Medicare, its 20% no matter how high the bill -- with these, it's 30-35%, but with different premiums you get different maximums...I've seen from $3500 to $9000. (Medical only, remember)

You'll get with that a prescription coverage plan, all of which end up in the same place if you have lots of meds - over $4550, you'll pay 5% -- all policies end up there, although they arrive there with different initial prescription costs.

If anyone comes up with a different synopsis, I'd love to here it -- heaven knows my lupie brain may have this totally upside down!

Cheers,
Lynnwood, Lupus & Sjogren's Moderator
"Life is far too important to be taken seriously" - Oscar Wilde


Bsime
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Date Joined Apr 2006
Total Posts : 1298
   Posted 12/17/2009 11:41 AM (GMT -7)   
Lynnwood,
 
If you have medicare a & b, a medigap supplement you can chose any doctor or hospital you want.  Nobody makes that choice for you although some of the private medigap plans charge less if you go to their preferred hospitals.  I have paid $0 since being on medicare.  Meds are another story.  There is a Plan D prescription plan finder on medicare where you put your meds in and it will find the best plans for you.  There are about 60 plans in IL and finding the right one would be nearly impossible otherwise.  I use Wellpoint and have no copays and my wife uses AARP.  We review it annually since the meds covered change every year....insanity.
 
 
 
I have paid $0 except for my insurance premiums this year with standard medicare (a&b), BC/BS medigap, and Wellpoint Part D and have had several expensive tests.  I also see my regular docs and have full control over whom I see.  My wife and I have found medicare to be very good but any insurer will have limitations and you will have to fight for some procedures and meds...both private and medicare.
 
Bill
MCTD (lupus, scleroderma, polymyositis).  Diagnosed 2005.  Kidney, liver, GI tract, dysphagia, raynauds, Barretts esophagus, quadriplegic in 2005.  Recovered and now active in skiing, tai, chi, hiking, golf.  Meds: prednisone 2.5mg, imuran 25mg, amlodipine, benazapril, omeprazole, potassium, folic acid, vitamins, maxide and various supplements and vitamins.
 
Remain optimistic and you can overcome the odds.


Lynnwood
Forum Moderator


Date Joined May 2005
Total Posts : 7018
   Posted 12/17/2009 10:35 PM (GMT -7)   
Bill,

It seems that there are no medigap/supplemental plans in my area that will cover persons under 65 -- as far as I can tell they are rare in any area.

So that leaves the Medicare Advantage plans if I want more than the 80% coverage Medicare provides. Or I could stick w/80% for medical coverage and just purchase a prescription plan.

With everything in flux nationally concerning health insurance, doctors and insurance companies are all scrambling around and changing who/what/when/where they are associated with. What a complication to and already complicated choice!

Do you find that you can use most any dr and hospital with just Medicare? You mention expensive tests - have you had any hospitalizations?

My lupus is "quiet" now, but I do have some expensive meds -- would you risk using just Medicare, is your faith in it that strong?

Sorry, I just don't have any Medicare users around me to question. If you'd rather chat in email my address is available.

Thanks
Lynnwood, Lupus & Sjogren's Moderator
"Life is far too important to be taken seriously" - Oscar Wilde


Bsime
Veteran Member


Date Joined Apr 2006
Total Posts : 1298
   Posted 12/18/2009 7:20 AM (GMT -7)   
Lynnewood,
 
I am surprised there are no medigap insurers in your state.  Where do you live?  If not, you would still be open for 20% which can be a lot of money and I would not want to be liable for that amount.  Have you gone to the plan finder  on the medicare site?
 
I have had out patient procedures but my wife has had major surgery......  it cost $0.  There is no problem with medicare coverage and we go to the doctors and hospitals we chose.  I did select a medigap plan that was a little less that has preferred hospitals (not doctors) for elective surgery.  For emergency purposes I could go anywhere.
 
NOTHING has changed in medicare and I believe that IF a healthcare bill is passed the way medicare will work will not appreciably change regardless of the nonsensical rhetoric you hear.  Those on medicare with the right medigap and plan D are very happy about the coverage.  The insurance payments are much less than private insurance and the coverage is 100% or near that.
 
For drugs you need a Plan D otherwise medicare does not cover drugs.  There is a doughnut hole that makes no sense and that is a problem.  You get coverage up to $2800 (that includes anything you pay + what the insurance pays) and then nothing to $4400.  Then the plans pay 100%.  Goofy.  There usually are some plan Ds that cover generic drugs in the hole and that is why you have to use the drug finder on the medicare site to find the best plan for you.
 
If you are asking me if I have any reservations about medicare...I do not.  It is almost as good as the private insurance I had 30+ years ago that paid everything...of course, you can't get such a policy today no matter what you pay or how healthy you are.  The changes that have been proposed for medicare do NOT reduce the coverage and the biggest changes are in the subsidies to the advantage plans which have not worked out as conceived.  Don't get caught up in all the political hype...it is inaccurate most of the time and wrong some of the time.
 
Bill
 
 
 
 
MCTD (lupus, scleroderma, polymyositis).  Diagnosed 2005.  Kidney, liver, GI tract, dysphagia, raynauds, Barretts esophagus, quadriplegic in 2005.  Recovered and now active in skiing, tai, chi, hiking, golf.  Meds: prednisone 2.5mg, imuran 25mg, amlodipine, benazapril, omeprazole, potassium, folic acid, vitamins, maxide and various supplements and vitamins.
 
Remain optimistic and you can overcome the odds.


SnowyLynne
Veteran Member


Date Joined Apr 2004
Total Posts : 1539
   Posted 12/18/2009 8:38 AM (GMT -7)   
You have to be 65 to get medigap insurance,& medicare part D.......I love mine.........
SnowyLynne


Bsime
Veteran Member


Date Joined Apr 2006
Total Posts : 1298
   Posted 12/18/2009 8:52 AM (GMT -7)   
If you have been on SSD for 2 years and are under 65 you can currently qualify for medicare A & B as well as part D.  I don't believe you can get a medigap policy until you are 65 under the current law.  I was able to get coverage before I was 65. 
 
More inconsistency in the program but it is a good one if you are 65+.
 
Bill
MCTD (lupus, scleroderma, polymyositis).  Diagnosed 2005.  Kidney, liver, GI tract, dysphagia, raynauds, Barretts esophagus, quadriplegic in 2005.  Recovered and now active in skiing, tai, chi, hiking, golf.  Meds: prednisone 2.5mg, imuran 25mg, amlodipine, benazapril, omeprazole, potassium, folic acid, vitamins, maxide and various supplements and vitamins.
 
Remain optimistic and you can overcome the odds.


Lynnwood
Forum Moderator


Date Joined May 2005
Total Posts : 7018
   Posted 12/18/2009 9:42 AM (GMT -7)   
Apparently there are *some* medigap policies if you are under 65 & on Medicare -- unfortunately there aren't many of them, and so far the Medicare site says none in my area. I have a couple of actual insurance agents looking.
Lynnwood, Lupus & Sjogren's Moderator
"Life is far too important to be taken seriously" - Oscar Wilde


Bsime
Veteran Member


Date Joined Apr 2006
Total Posts : 1298
   Posted 12/18/2009 9:50 AM (GMT -7)   
Lynnwood,
 
You are right.  AFter I posted I remembered a younger friend of mine on disability telling me there were in IL....only 1 or 2 and quite expensive I think.  They are much more reasonable when you turn 65.  He had other insurance options from the military and also work so he did not pursue it further.
 
Bill
MCTD (lupus, scleroderma, polymyositis).  Diagnosed 2005.  Kidney, liver, GI tract, dysphagia, raynauds, Barretts esophagus, quadriplegic in 2005.  Recovered and now active in skiing, tai, chi, hiking, golf.  Meds: prednisone 2.5mg, imuran 25mg, amlodipine, benazapril, omeprazole, potassium, folic acid, vitamins, maxide and various supplements and vitamins.
 
Remain optimistic and you can overcome the odds.


Lynnwood
Forum Moderator


Date Joined May 2005
Total Posts : 7018
   Posted 12/18/2009 9:54 AM (GMT -7)   
The whole "life is better once you get Medicare" line of thinking is looking very dubious...
Lynnwood, Lupus & Sjogren's Moderator
"Life is far too important to be taken seriously" - Oscar Wilde


Bsime
Veteran Member


Date Joined Apr 2006
Total Posts : 1298
   Posted 12/18/2009 10:33 AM (GMT -7)   
None of us know if there will be any changes to medicare in the future that affect insurees. There have been a lot of outright lies about healthcare reform to prevent any meaningful reform but I don't believe medicare will change significantly as far as patients are concerned.  If reform passes, which is in doubt, it will make many back end changes to medicare...not much on the front end for patients.  The funding for medicare is inadequate for the future and that will have to be addressed.  Don't know if the current legislation does that or not....it changes every hour I think.  Medicaid has no funding and is a big problem.  A friend of mine who is an economist wrote a book on SS, medicare and medicaid and pointed out a lot of the myths about these programs. 
 
Private insurance continues to go up at 15% or more a year, deny coverage, set lifetime limits, and deny procedures, etc.  If we don't have medicare in the future we will truly have a healthcare hell for seniors who as a group are very pleased with it.  Fewer companies are providing benefits, many small companies cannot afford them at all, and all companies are passing on the costs more and more to employees.  There has been a nasty game going on for years of firing older workers who are benefit liabilities.  We have a mess and I don't think the current bill in whatever form it finally takes will address all of these problems...particularly not the cost.  Private insurance companies will not address those and add 30-40% overhead whereas medicare only adds about 4%.  If we did not have medicare senior would not have any healthcare because they would not qualify and if they did most could not afford it.  A sure death sentence to many older patients.
 
Putting all of this aside, my wife and I have a combined 6 years on medicare and it works great.  Hope it stays that way but like everything, who knows.  Good luck in finding the right solution for you.
 
Bill
MCTD (lupus, scleroderma, polymyositis).  Diagnosed 2005.  Kidney, liver, GI tract, dysphagia, raynauds, Barretts esophagus, quadriplegic in 2005.  Recovered and now active in skiing, tai, chi, hiking, golf.  Meds: prednisone 2.5mg, imuran 25mg, amlodipine, benazapril, omeprazole, potassium, folic acid, vitamins, maxide and various supplements and vitamins.
 
Remain optimistic and you can overcome the odds.


cured4real?
Veteran Member


Date Joined Dec 2005
Total Posts : 1944
   Posted 12/22/2009 12:32 AM (GMT -7)   
In GA you cannot get medigap until you are 65 but you can get part D drug plan. The GA state "approved drug plan" is Community Care RX,which is what I have and the state picks up the tab-- about 45 bucks a month. I have straight medicare and you should find that participating docs will write off the excess they normally charge and you will pay less than if you have a MAP Plan, because you aren't paying the monthly premiums. I can't be on one becase of Mayo, who hates them and won't take any of them. Almost no one in Florida will take them. If you qualify,you can get medicaid as well as medicare, you can apply through medicare 800 number. I get th max amount of social security and am 60 bucks too high to get it, so the limit is high. Then medicaid pays for what medicare doesn't, it is secondary to medicare.

IF you go to Emory, they may be able to tell you what a consult with your doc would be on straight medicare. Medicaid is nice because it includes all the things that should be in medicare, like free transportation to the doctors if you cannot get there, and some additional things. It also helps with the drugs and copays. You should pay nothing, as long as the docs take both. GA, unlike most states, seems to be really medicare/medicaid friendly and we havemuch better access to better quality of care than in most other states. I have really good docs and all of them take both medicaid and medicare and adjust their rates and are real reasonable.

In FL, like many other states, very few good docs take medicare andmedicaid, with the exception of Jacksonville area and the Universities. It really depends where you go. For me, my Humana PPO would be 200 bucks a month, I would have a 15 buck copay to my family doc, 30 to a specialist. When I went off Humana, I was so mad because so far all my docs have only charged me 17 bucks for each appt. My copays on other stuff is the same as on Humana as well. The insurance company has to make its money somehow. Mayo said they don't take them because they can't get payment from them, and they feel they take advantage of people.

Medigap would be great. Just can't get it yet.
Love, Marji
Ills--Sjogrens-Lupus cond., AI polygland. dysfunction 2, hyper/hypopigment, scoliosis,kyphosis,stenosis, deg.,O.A.,spine surgeries, salivary/lymphectomies, NASH, COPD, RLS, UT/GI bleeds, hystero, brain/nerve damage,TB
Meds--INH,Plaquenil, Evoxac, Metformin, Synthroid, HCTZ, HRT and Lidocaine patchs, Voltaren gel, Klonopin, Vicodin, Restasis, Albuterol, steroids

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